Child asthma

DR S RAGHU M.D.,
ASST PROF
DEPT. T B & CD
GUNTUR MEDICAL
COLLEGE
GUNTUR
Dr s. raghu m.d.,
Associate professor
Department of TB & CD
R I M S medical college
ONGOLE

100 m2
10,000 L blood pass
every 24 hrs
10,000 L blood pass
every 24 hrs
10,000 L air in &
out every 24 hrs
10,000 L air in &
out every 24 hrs
350 L of O2 delivered every day350 L of O2 delivered every day
100 m2
10,000 L blood pass
every 24 hrs
10,000 L blood pass
every 24 hrs
10,000 L air in &
out every 24 hrs
10,000 L air in &
out every 24 hrs
350 L of O2 delivered every day350 L of O2 delivered every day

Definition:
Asthma is a chronic inflammatory disorder of the airways in which
many cells & cellular events play a role.
The chronic inflammation is ass with airway hyperresponsiveness
that leads to recurrent episodes of wheezing, breathlessness, chest
tightness & coughing, particularly at night or in the early morning.
These episodes are usually ass with widespread but variable
airflow obstruction within the lung that is often reversible either
spontaneously or with treatment.
GINA 2011

Asthma
is a
Chronic Inflammatory Disease
characterized by
Airway Hyperresponsiveness
to a variety of stimuli resulting in
Bronchospasm
which reverses, spontaneously
or with treatment.

150 million people in the world(including
many children) do not take breathing for
granted
WHO says- asthma is becoming most
common chronic disease in children

 Asthma is a chronic disease most
responsible for days off school.
 Night-time awakenings can affect a child’s
concentration in school next day
 Asthma significantly affects sports and
recreational activities
 Missed days of school can affect a child's
future career
( WHO estimates 14 million school days are lost every year due to
Asthma across the globe )

What happens in Asthma……….
Spasm & Swelling

20 million people with asthma
10-15% of children are sufferer
Spread over rural & urban sector
Not sparing affluent class

Growing urbanisation & life style change
Junk food
3 major pollens – Parthenium, Casuarina
and Eucalyptus have increased
Increase in no. of industries and
automobiles
Smoking
Ind J Ped 2002;69:309-12

By 1 year – 26%
1-5 years – 51.4%
> 5 years – 22.3%
Ind J Ped 2002;69:309-12
77% of all asthma begin in children less than 5
years

• Commonest chronic disease in children.
• More than 77% of the children present below the
age of 5 years,
• The presentation closely mimics many conditions
common in this age group
• The diagnostic modalities both spirometry and
peak expiratory flow rate cannot be used in
children below the age of 5 yrs

• Parents are proxy story tellers on behalf of
the patients, and may exaggerate or
undermine the nature of the disease.
• All this may lead to delayed diagnosis.
• Acceptance of inhalation therapy is
another hurdle in the management of
asthma

Recurrent cough with or without
breathlessness
Nocturnal cough without viral respiratory
tract infection
Recurrent breathlessness

Tightness of chest
Seasonal variability
Triggers
Exercise induced exacerbation
Family or personal history of
asthma/atopy/allergy

What are the Triggers?
* Infections (Viral)
*Strongsmells,perfumes
deodorants
* Pets
* House dust
* Pollen
* Tobacco smoke
* Pollution
* Climate (Cold days Humid days)
* Exercise
* Emotion
* Food Additives
Colouring agents preservatives
* Drugs

Normal individual
 Allergen stimulates production
of IgE, in equal no. to allergen.
 Allergen  destroyed
Allergic individual
 Allergen stimulates excess
production of IgE.
 Some Allergens get destroyed.
 Rest cause allergic reaction.

Associated conditions
• Eczema
• Rhinitis
• Hay fever
Relief with bronchodilators with or without
oral steroids
Weight & Height

Afebrile episodes
Personal atopy

 step 1 Good Clinical
History
 step 2 Careful
Physical
Examination
 step 3 Investigations

Spirometry
Spirometry can be performed
when diagnosis is in doubt as
well as for periodic monitoring of
asthma.
Disadvantages
• Cannot be done in children
below the age of 5 yrs
• Technical expertise required

Measurement of Peak expiratory flow
rate (PEFR) with a peak flow meter
The peak expiratory flow rate is the easiest
to perform in children above the age of 5
yrs. It can help the patient assess the
presence of wheezing and can help in self-
monitoring.

It is highly suggestive of asthma if there is:
 ≥ 20% increase in PEFR after inhaled
short-acting beta2 agonist
 ≥ 20% decrease in PEFR after exercise
Diurnal variation ≥ 20% in children not on
bronchodilator

• Normally a diurnal variation <10% in PEFR
values is observed. Lowest levels are seen on
waking and highest levels about 12 hours
later

 Other tests-
 Complete Blood
Count (CBC),
 Chest X-Ray - help to
rule out alternative
diagnosis rather than
diagnose asthma.
 Asthma is a clinical
diagnosis

Early infancy: birth -
6 months (seldom
Asthma)
Infancy-early
childhood 6 months
- 3 years (asthma
Probable)
Late childhood:
> 3 years (most
likely asthma)
Aspiration Syndromes Bronchiolitis Asthma
Bronchiolitis Transient Wheezing of
Childhood (TWC)
TWC
Congenital
Heart Disease
Early onset asthma foreign body aspiration
Congenital
Malformations of
Respiratory Tract
Foreign body aspiration congenital heart disease
Congenital
Heart Disease
Infection like TB, etc

Stridor/Noisy breathing
Viral mediated hyper-reactive airways
Tuberculosis and Pertussis
Foreign body
Tropical eosinophilia

Presence of these can make control of
asthma difficult and hence they should be
identified and treated:
Allergic Rhinitis
Adenoidal Hypertrophy
Gastro Oesophageal Reflux Disease
(GORD or GERD)

All Asthma Does Not Wheeze
Recurrent cough
Tightness of chest

Firstly, and most importantly, it is
necessary to inform about the chronic
nature of asthma, including the fact of
acute exacerbations in between episodes
Emphasize on the point that this disease is
controllable but not curable.

Also, emphasize on the fact that inhalation
therapy is the gold standard treatment for
asthma.
At the same time, the myths and the
misconceptions about inhalation therapy
should be resolved.
Discuss the selected regime and address
the concerns regarding steroid use.

Discuss the usage and maintenance of the
inhaler device. Also advise on bringing the
device along for each follow-up.
Emphasize on the need for a regular
follow-up.
Explain the need for adherence with the
treatment .

Advise regarding avoidance of triggers.
Note that diet has a limited role in the
causation of asthma.
Patients / parents should be advised to
maintain a diary to record the significant
events and carry it with them every time
they go for a follow-up.

By significant events, we mean daytime
cough, night time cough, reliever
medication use, emergency visits, etc.
Educate regarding the management of
acute exacerbations at home prior to
visiting a doctor

Viral infections
Smoke - cigarettes, kitchen, etc.
Fungi, mold, spores
Pets
Food items known to cause asthma
Aspirin/NSAID sensitivity
Beta-blocker-induced bronchospasm
Obesity

 Humidity
 Weather
 Industrial and
automobile pollution

Oral Inhaled Parenteral
Tablets
Syrup
Metered dose inhaler (MDI)
Dry powder inhaler (DPI)
Injections
Which is the best route for anti-asthmatic drugs???
Nebulizers

WHY INHALATION THERAPY?
Small doses of Drug
High Local
Concentration
Low Systemic
Concentration
Efficacy Safty

Less Drug
Without Side effects
Straight into the
Lungs
Why Inhaled Therapy ?
Salbutamol 4 mg Tabs
40 Puffs of salbutamol Inh

The health-care
provider should
evaluate inhaler
technique at
each visit.

Symptoms Nocturnal
symptoms
FEV1/PEF
Intermittent <1 time a week ≤ 2 times a month ≥ 80% predicted
Variability < 20%
Mild persistent > 1 time a week
but < 1 time a day
>2 times a month ≥ 80% predicted
Variability
20 - 30%
Moderate
persistent
Daily attacks
affect activity
>1 time a week 60 - 80%
predicted
Variability > 30%
Severe persistent Continuous
limited physical
activity
Frequent ≤ 60% predicted
Variability > 30%

Characteristic Controlled Partly controlled
(Any present in any week)
Uncontrolled
Daytime symptoms
None (2 or less /
week)
More than
twice / week
3 or more
features of
partly
controlled
asthma
present in
any week
Limitations of
activities
None Any
Nocturnal
symptoms /
awakening
None Any
Need for rescue /
“reliever” treatment
None (2 or less /
week)
More than
twice / week
Lung function
(PEF or FEV1)
Normal
< 80% predicted or
personal best (if
known) on any day
Exacerbation None One or more / year 1 in any week

A dose response study using budesonide
in children with moderate and severe
persistent asthma indicated that 83%
achieved control of exercise induced
asthma with a dose of 400 mcg/day .
There is little risk of systemic effects if
inhaled corticosteroids are used in doses
of less than 400 μg/day (beclomethasone
equivalent).
von Berg A, Engelstatter R, Minic P, Sreckovic M, Garcia MLG,
Latos L et al.

 Following commencement of therapy, the
dose of inhaled corticosteroid should be
titrated according to clinical response, aiming
for the minimum dose that will provide
continuing control of asthma symptoms.
 While the majority of studies of inhaled
corticosteroids in children have employed
twice daily dosing, studies with ciclesonide
have demonstrated that that once daily
dosing is effective .

The dose of inhaled corticosteroid
delivered to the lungs will depend on many
factors including the delivery device, the
age of the child, individual variation in
inhaler technique, and adherence.
Pedersen S, Engelstatter R, Weber H-J,
Hirsch S,
Barkai L, Eneryk A et al.

 Majority of studies have used 2mg/kg oral
prednisolone , (maximum 60 mg) given
initially and subsequently daily doses of
1mg/kg if required.

Duration of therapy will generally be up to
3 days (a 5 day course has not been
shown to confer any advantage over a 3
day course in non hospitalized children ,
but in patients with severe persistent
asthma a more prolonged course may
occasionally be needed with tapering of
the dose to prevent asthma relapse.

Although a recent comparison of oral
dexamethasone(0.6mg/kg) with oral
prednisololone (2mg/kg) demonstrated that
a shorter course of dexamethasone
provided equal benefit and was better
tolerated , concerns were raised about the
greater potential for adrenal suppression
with dexamethasone related to its longer
half-life.

 While there appears to be no definite advantage of
parenteral over oral corticosteroids ,
 intravenous corticosteroids (methylprednisolone in an
initial dose of 2mg/kg, up to 60mg, subsequent doses
1mg/kg every 6 hours on day 1, then every 12 hours
on day 2, then daily) will be needed if the child is
extremely ill, unconscious, or cannot tolerate oral
medication.
 Hydrocortisone 8-10mg/kg (max 300mg) initially then
4-5mg/kg/dose can be used as an alternative
parenteral corticosteroid.

Short bursts of oral corticosteroids (3 to 10
days) are administered to children with
acute asthma exacerbations.
 The initial starting dose is 1 to 2
mg/kg/day of prednisone followed by 1
mg/kg/day over the next 2 to 5 days.
(nelson text book of paeds)

controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROL
maintain and find lowest
controlling step
consider stepping up to
gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTION
TREATMENT STEPS
REDUCE INCREASE
STEP
1
STEP
2
STEP
3
STEP
4
STEP
5
REDUCEINCREASE

Infants Nebulizer
Children
< 4 years Nebulizer/ MDI with
spacer with facemask
4 -6year MDI with Spacer
>6 years DPI
>12years MDI
 Acute episodes Nebulizer

The prescribed treatment can be considered
effective when:
The child is normal and asymptomatic
He/she is not awakened by symptoms of
asthma
He/she can go to school and have a
normal lifestyle
He/she can play with the peers without
getting any symptoms

 Exacerbations of
asthma (asthma
attacks) are episodes
of a progressive
increase in shortness
of breath, cough,
wheezing or chest
tightness or a
combination of these
symptoms.

The economic costs of asthma are
estimated to be more than those of
HIV/AIDS and tuberculosis combined.

Oxygen is given if the patient is hypoxemic
(achieve O2 saturation of 92%- 95%).
Inhaled rapid-acting ß2 -agonists such as
salbutamol or levosalbutamol in adequate
doses are essential
First hour 2-4 puffs Every 20 mts
Mild 2-4 puffs 3-4 hrs
moderate 6-10 puffs 1-2 hrs

 Oral glucocorticosteroids 0.5–1 mg of
prednisolone/kg or equivalent
introduced early in the course of a
moderate or severe attack help to
reverse the inflammation and speed
recovery

Methylxanthines are not recommended
routinely. However, theophylline can be
used if inhaled ß2- agonists are not
available.
 If the patient is already taking theophylline
on a daily basis, serum concentration
should be measured before adding short-
acting theophylline.

Sedatives (strictly avoid).
 Mucolytic drugs (may worsen cough).
Chest physical therapy/physiotherapy
(may increase patient discomfort).

Hydration with large volumes of fluid in
case of adults and older children (may be
necessary for younger children and
infants).
Antibiotics (do not treat attacks, but are
indicated for patients who also have
pneumonia or bacterial infection such as
sinusitis).

A subcutaneous or intramuscular injection
of epinephrine (adrenaline) may be
indicated for acute treatment of
anaphylaxis and angio-oedema, but is not
routinely indicated during asthma attacks.
 Intravenous magnesium sulphate has not
been well-studied in young children and is
usually used when all the above fails.

Asthma is the most common chronic
disorder affecting children – 5%-10%
Up to 2-3 children in each classroom may
be affected by asthma
It is a serious disease and can be fatal

A majority of children affected by asthma
are undiagnosed, misdiagnosed or
unlabeled
Over 50% of children remain uncontrolled
and hence can affect school performance

Traditional treatment
Occasional RelieversIdeal treatment
Regular Controllers
Steroid

 Minimal (ideally no) chronic symptoms
 Minimal (ideally no) need for “as needed” use of relievers
 No emergency visits
 (Near) normal PEF
 Minimal (infrequent) exacerbations
 PEF circadian variation of less than 20 percent
 No limitations on activities, including exercise
 Minimal (or no) adverse effects from medicine

 Routes of administration of anti-asthma drugs
 Advantages of inhalation therapy over oral
route
 Drug therapy for asthma
 Differences between relievers and controllers

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Child asthma

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